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Guide to Quitting Smoking

 

Double your chances
of quitting for good.
Call 1-800-ACS-2345
to speak with someone who can help.


Contents
Why Should I Quit?
How to Quit
Dealing With Withdrawal
Staying Quit
Support
Weight Gain
Stress
The US Surgeon General has stated, "Smoking cessation (stopping smoking) represents the single most important step that smokers can take to enhance the length and quality of their lives."

Quitting smoking is not easy, but it can be done. To have the best chance of quitting successfully, you need to know what you’re up against, what your options are, and where to go for help. This document is intended to provide you with this information.

Why Is It So Hard to Quit Smoking?

Mark Twain said, "Quitting smoking is easy. I've done it a thousand times." Maybe you've tried to quit too. Why is quitting and staying quit hard for so many people? The answer is nicotine.

Nicotine

Nicotine is a drug found naturally in tobacco. It is highly addictive – as addictive as heroin or cocaine. Over time, the body becomes physically and psychologically dependent on nicotine. Studies have shown that smokers must overcome both of these to be successful at quitting and staying quit.

When smoke is inhaled, nicotine is carried deep into the lungs, where it is absorbed quickly into the bloodstream and carried throughout the body. Nicotine affects many parts of the body, including your heart and blood vessels, your hormonal system, your metabolism, and your brain. Nicotine can be found in breast milk and in cervix mucous secretions of smokers. During pregnancy, nicotine freely crosses the placenta and has been found in amniotic fluid and the umbilical cord blood of newborn infants.

Several different factors can affect the rate of metabolism and excretion of nicotine. In general, a regular smoker will have nicotine or its by-products present in the body for about 3 to 4 days after stopping.

Nicotine produces pleasurable feelings that make the smoker want to smoke more. It also acts as a kind of depressant by interfering with the flow of information between nerve cells. As the nervous system adapts to nicotine, smokers tend to increase the number of cigarettes they smoke, and hence the amount of nicotine in their blood. After a while, the smoker develops a tolerance to the drug, which leads to an increase in smoking over time. Eventually, the smoker reaches a certain nicotine level and then smokes to maintain this level of nicotine.

Nicotine Withdrawal

When smokers try to cut back or quit, the absence of nicotine leads to withdrawal symptoms. Withdrawal is both physical and mental. Physically, the body is reacting to the absence of nicotine. Psychologically, the smoker is faced with giving up a habit, which is a major change in behavior. Both must be dealt with if quitting is to be successful.

Withdrawal symptoms can include any of the following:

  • dizziness (may only last 1-2 days in the beginning)
  • depression
  • feelings of frustration and anger
  • irritability
  • trouble sleeping
  • trouble concentrating
  • restlessness
  • headache
  • tiredness
  • increased appetite

These symptoms can lead the smoker to again start smoking cigarettes to boost blood levels of nicotine back to a level where there are no symptoms.

If a person has smoked regularly for a few weeks or longer and abruptly stops using tobacco or greatly reduces the amount smoked, withdrawal symptoms will occur. Symptoms usually start within a few hours of the last cigarette and peak about 2 to 3 days later. Withdrawal symptoms can last for a few days to several weeks. For information on coping with withdrawal, see the section, "How to Quit."

Why Quit?

Your Health

Health concerns usually top the list of reasons people give for quitting smoking. About half of all smokers who continue to smoke will end up dying from a smoking-related illness. Nearly everyone knows that smoking can cause lung cancer, but few people realize it is also a risk factor for many other kinds of cancer as well, including cancer of the mouth, voice box (larynx), throat (pharynx), esophagus, bladder, kidney, pancreas, liver, cervix, stomach, colon and rectum, and some leukemias.

Smoking increases the risk of lung diseases such as emphysema and chronic bronchitis. These progressive lung diseases – grouped under the term COPD (chronic obstructive pulmonary disease) – are usually diagnosed in current or former smokers in their 60s and 70s. COPD causes chronic illness and disability and is eventually fatal.

Smokers are twice as likely to die from heart attacks as are nonsmokers. And smoking is a major risk factor for peripheral vascular disease, a narrowing of the blood vessels that carry blood to the leg and arm muscles, as well as cerebrovascular disease that can cause strokes.

Smoking also causes premature wrinkling of the skin, bad breath, bad smelling clothes and hair, and yellow fingernails and hair, yellow fingernails and increased risk of macular degeneration, one of the most common causes of blindness in the elderly.

For women, there are unique risks. Women over 35 who smoke and use birth control pills are in a high-risk group for heart attack, stroke, and blood clots of the legs. Women who smoke are more likely to have a miscarriage or a lower birth-weight baby. Low birth-weight babies are more likely to die or to be permanently impaired.

Based on data collected in the late 1990s, the US Centers for Disease Control (CDC) estimated that adult male smokers lost an average of 13.2 years of life and female smokers lost 14.5 years of life because of smoking.

No matter what your age or how long you've smoked, quitting will help you live longer. People who stop smoking before age 35 avoid 90% of the health risks attributable to tobacco. Even those who quit later in life can significantly reduce their risk of dying at a younger age.

Ex-smokers also enjoy a higher quality of life with fewer illnesses from cold and flu viruses, better self-reported health status, and reduced rates of bronchitis and pneumonia.

For decades the Surgeon General has reported the health risks associated with smoking. Regardless of your age or smoking history, there are advantages to quitting smoking. Benefits apply whether you are healthy or you already have smoking-related diseases. In 1990, the Surgeon General concluded:

  • Quitting smoking has major and immediate health benefits for men and women of all ages. Benefits apply to people with and without smoking-related disease.
  • Former smokers live longer than continuing smokers. For example, people who quit smoking before age 50 have one-half the risk of dying in the next 15 years compared with continuing smokers.
  • Quitting smoking decreases the risk of lung cancer, other cancers, heart attack, stroke, and chronic lung disease.
  • Women who stop smoking before pregnancy or during the first 3 to 4 months of pregnancy reduce their risk of having a low birth weight baby to that of women who never smoked.
  • The health benefits of quitting smoking far exceed any risks from the average 5-pound weight gain or any adverse psychological effects that may follow quitting.

When Smokers Quit – What Are the Benefits Over Time?

20 minutes after quitting: Your heart rate drops.
(US Surgeon General's Report, 1988, pp. 39, 202)

12 hours after quitting: The carbon monoxide level in your blood drops to normal.
(US Surgeon General's Report, 1988, p. 202)

2 weeks to 3 months after quitting: Your circulation improves and your lung function increases.
(US Surgeon General's Report, 1990, pp.193,194,196,285,323)

1 to 9 months after quitting: Coughing and shortness of breath decrease; cilia (tiny hair like structures that move mucus out of the lungs) regain normal function in the lungs, increasing the ability to handle mucus, clean the lungs, and reduce the risk of infection.
(US Surgeon General's Report, 1990, pp. 285-287, 304)

1 year after quitting: The excess risk of coronary heart disease is half that of a smoker's.
(US Surgeon General's Report, 1990, p. vi)

5 years after quitting: Your stroke risk is reduced to that of a nonsmoker 5-15 years after quitting.
(US Surgeon General's Report, 1990, p. vi)

10 years after quitting: The lung cancer death rate is about half that of a continuing smoker's. The risk of cancer of the mouth, throat, esophagus, bladder, cervix, and pancreas decrease.
(US Surgeon General's Report, 1990, pp. vi, 131, 148, 152, 155, 164,166)

15 years after quitting: The risk of coronary heart disease is that of a nonsmoker's.
(US Surgeon General's Report, 1990, p. vi)

Visible and Immediate Rewards of Quitting

Quitting helps stop the damaging effects of tobacco on your appearance including:

  • premature wrinkling of the skin
  • bad breath
  • stained teeth
  • gum disease
  • bad smelling clothes and hair
  • yellow fingernails

Kicking the tobacco habit also offers benefits that you'll notice immediately and some that will develop gradually in the first few weeks. These rewards can improve your day-to-day life substantially:

  • Food tastes better.
  • Sense of smell returns to normal
  • Ordinary activities no longer leave you out of breath (climbing stairs, light housework, etcetera.)

The prospect of better health is a major reason for quitting, but there are others as well.

Cost

Smoking is expensive. It isn't hard to figure out how much you spend on smoking: multiply how much money you spend on tobacco every day by 365 (days per year). The amount may surprise you. Now multiply that by the number of years you have been using tobacco and that amount will probably astound you.

Multiply the cost per year by 10 (for the upcoming 10 years) and ask yourself what you would rather do with that much money.

And this doesn’t include other possible expenses, such as higher costs for health and life insurance, as well as the health care costs due to tobacco-related conditions.

Social Acceptance

Smoking is less socially acceptable now than it was in the past.

Most workplaces have some type of smoking restrictions. Some employers even prefer to hire nonsmokers. Studies show smoking employees cost businesses more to employ because they are "out sick" more frequently. Employees who are ill more often than others can raise an employer’s need for expensive temporary replacement workers. They can increase insurance costs both for other employees and for the employer, who typically pays part of the workers’ insurance premiums. Smokers in a building also typically increase the maintenance costs of keeping odors at an acceptable level, since residue from cigarette smoke clings to carpets, drapes, and other fabrics.

Landlords, also, may choose not to rent to smokers since maintenance costs and insurance rates may rise when smokers occupy buildings.

Friends may ask you not to smoke in their houses or cars. Public buildings, concerts, and even sporting events are largely smoke-free. And more and more communities are restricting smoking in all public places, including restaurants and bars. Like it or not, finding a place to smoke can be a hassle.

Smokers may find their opportunities for dating or romantic involvement, including marriage, are largely limited to other smokers, who make up only about 1/4th of the population.

Health of Others

Smoking not only harms your health but the health of those around you. Exposure to secondhand smoke (also called environmental tobacco smoke or passive smoking) includes exhaled smoke as well as smoke from burning cigarettes.

Studies have shown that secondhand smoke causes thousands of deaths each year from lung cancer and heart disease in healthy nonsmokers.

Smoking by mothers is linked to a higher risk of their babies developing asthma in childhood, especially if the mother smokes while pregnant. It is also associated with sudden infant death syndrome (SIDS) and low-birth weight infants. Babies and children raised in a household where there is smoking have more ear infections, colds, bronchitis, and other respiratory problems than children from nonsmoking families. Secondhand smoke can also cause eye irritation, headaches, nausea, and dizziness.

Setting an Example

If you have children, you probably want to set a good example for them. When asked, nearly all smokers say they don't want their children to smoke, but children whose parents smoke are more likely to start smoking themselves. You can become a good role model for them by quitting now.

Help Is Available

With the wide array of counseling services, self-help materials, and medicines available today, smokers have more tools than ever before to help them quit successfully.

Remember, tobacco addiction has both a psychological and a physical component. For most people, the best way to quit will be some combination of medicine, a method to change personal habits, and emotional support. The following sections describe these tools and how they may be helpful for you.

In This Section:

What About Nicotine Replacement Therapy?
Types of Nicotine Substitutes
Which Is Right for You?
Other Methods of Quitting
Telephone Counseling
Support
A Word About Success Rates
Special Concerns
Where Can I Go for Help

Help With Psychological Addiction

Some people are able to quit on their own, without the help of others or the use of medicines. But for many smokers, it can be hard to break the social and emotional ties to smoking while getting over nicotine withdrawal symptoms at the same time. Fortunately, there are many sources of support out there – both formal and informal.

Quitlines – Telephone-based Help to Stop Smoking

Most states run some type of free telephone "Quitline," which links callers with trained counselors. These specialists help plan a quit method that fits each person's unique smoking pattern. People who use telephone counseling stop smoking at twice the rate of those who don't get this type of help. With guidance from a counselor, quitters can avoid common mistakes that may hurt a quit attempt.

Telephone counseling is also more convenient for many people than some other support programs. It doesn't require transportation or childcare, and it's available nights and weekends. Counselors may recommend a combination of methods including medicines, local classes, self-help brochures, and/or a network of family and friends.

Smokers can get help finding a Quitline in their area by calling ACS at 1-800-ACS-2345.

Support of Family, Friends, and Quit Programs

Many former smokers say a support network of family and friends was very important during their quit attempt. Other people who may offer support and encouragement are coworkers, your family doctor, and members of support groups for quitters. You can check with your employer, health insurance company, or local hospital to find support groups; or call the ACS at 1-800-ACS-2345.

What to Look for in a Stop-Smoking Program

Stop smoking programs are designed to help smokers recognize and cope with problems that come up during quitting and to provide support and encouragement in staying quit. Studies have shown that the best programs will include either individual or group counseling. There is a strong association between the intensity of counseling and the success rate. In general, the more intense the program, the greater the likelihood of success.

Intensity may be increased by having more or longer sessions or by increasing the number of weeks over which the sessions are given. So, when considering a program, look for one that has the following:

  • session length – at least 20 to 30 minutes per session
  • number of sessions – at least 4 to 7 sessions
  • number of weeks – at least 2 weeks

Be certain the leader of the group has training in smoking cessation.

Some communities have a Nicotine Anonymous group that holds regular meetings. This group applies the principles of Alcoholics Anonymous to the addiction of smoking. There is no fee to attend.

Often your local American Cancer Society, American Lung Association, or local health department will sponsor quit smoking classes. Call 1-800-ACS-2345 for more information.

There are some programs to watch out for as well. Not all programs are ethical. Be very careful of programs that do the following:

  • Promise instant, easy success with no effort on your part.
  • Use injections or pills, especially "secret" ingredients (nicotine replacement is covered elsewhere).
  • Charge a very high fee. Check with the Better Business Bureau if you have doubts.
  • Are not willing to provide references from people who have taken the class.

Help With Physical Addiction: Nicotine Replacement Therapy

As mentioned earlier, the nicotine in cigarettes leads to actual physical dependence, which can cause unpleasant symptoms when a person tries to quit. Nicotine replacement therapy (NRT) provides nicotine – in the form of gums, patches, sprays, inhalers or lozenges – without the other harmful components of tobacco. It can help relieve some of these symptoms so that a person can concentrate more on the psychological aspects of quitting.

How Nicotine Replacement Works

Nicotine substitutes treat the very difficult withdrawal symptoms and cravings that 70% to 90% of smokers say is their only reason for not giving up cigarettes. By using a nicotine substitute, a smoker's withdrawal symptoms are reduced.

While a large number of smokers are able to quit smoking without nicotine replacement, most of those who attempt quitting are not successful on the first try. In fact, smokers usually need several attempts – sometimes as many as 8 to 10 – before they are able to quit for good.

Lack of success is often related to the onset of withdrawal symptoms. By reducing these symptoms with the use of nicotine replacement therapy, smokers who want to quit have a better chance of being successful.

Getting the Most From Nicotine Replacement

Nicotine replacement therapy only deals with the physical aspects of addiction. It is not intended to be the only method used to help you quit smoking. It should be combined with other smoking cessation methods that address the psychological component of smoking, such as a stop smoking program. Studies have shown that approach - pairing NRT with a program that helps to change behavior – can double your chances of successfully quitting.

The US Agency for Healthcare Research and Quality (AHRQ) Clinical Practice Guideline on Smoking Cessation recommends NRT for all smokers except pregnant women and people with heart or circulatory diseases. If a health care provider suggests nicotine replacement for people in these groups, the benefits of smoking cessation must outweigh the potential health risk. Smokers who are pregnant or have heart disease should consult with their doctor before using over-the-counter nicotine replacement.

The most effective time to start NRT is at the beginning of an attempt to quit. But often smokers first try to quit on their own, then decide to try NRT.

Nicotine replacement therapy should not be used if you plan to continue to smoke or use another tobacco product. The combined dose of nicotine could be dangerous to your health.

Types of Nicotine Substitutes

Five types of nicotine replacement therapy have been approved for use by the US Food and Drug Administration (FDA).

Nicotine patches (transdermal nicotine systems): Patches provide a measured dose of nicotine through the skin. As the nicotine doses are lowered by switching patches over a course of weeks, the tobacco user is weaned off nicotine. Patches can be purchased without a prescription. Several types and different strengths are available. Package inserts describe how to use the product as well as special considerations and possible side effects.

  • The 16-hour patch works well for light-to-average tobacco users. It is less likely to cause side effects like skin irritation, racing heartbeat, sleep problems, and headache. But it does not deliver nicotine during the night, so it is not helpful for early morning withdrawal symptoms.

  • The 24-hour patch provides a steady dose of nicotine, avoiding peaks and troughs. It helps with early morning withdrawal. However, there may be more side effects such as disrupted sleep patterns and skin irritation.

Depending on body size, most tobacco users should start using a full-strength patch (15-22 mg of nicotine) daily for 4 weeks, and then use a weaker patch (5-14 mg of nicotine) for another 4 weeks. The patch should be applied in the morning to a clean, dry area of the skin without much hair. It should be placed below the neck and above the waist - for example, on the arm. The FDA recommends using the patch for a total of 3 to 5 months. However, some studies have shown that using it for 8 weeks or less is just as effective as using it for longer.

Side effects are related to:

  • the dose of nicotine
  • the brand of patch
  • your individual skin characteristics (such as the person’s tendency to have a skin reaction to the patch)
  • how long you use the patch
  • how it is applied

Some possible side effects of the nicotine patch include:

  • skin irritation – redness and itching
  • dizziness
  • racing heartbeat
  • sleep problems or unusual dreams
  • headache
  • nausea
  • vomiting
  • muscle aches and stiffness

What to do about side effects:

  • Try a different brand of patch if skin irritation occurs.
  • Reduce the amount of nicotine by using a lower dose patch.
  • Sleep problems may be temporary and pass within 3 or 4 days. If not (and you're using a 24-hour patch), try switching to a 16-hour patch.
  • Stop using the patch and try a different form of nicotine replacement.

Nicotine gum (nicotine polacrilex): Nicotine gum is a fast-acting form of replacement that acts through the mucous membrane of the mouth. It can be bought over-the-counter without a prescription. It comes in 2 mg and 4 mg strengths.

For best results, follow the instructions of the package insert. Chew the gum slowly until you note a peppery taste. Then, "park" it against the cheek, chewing it and parking it off and on for about 20 to 30 minutes. Food and drink can affect how well the nicotine is absorbed. You should avoid acidic foods and drinks such as coffee, juices, and soft drinks for at least 15 minutes before and during gum use.

If you smoke a pack or more per day, smoke within 30 minutes of rising, or have trouble not smoking in restricted areas, you may need to start with the higher dose (4 mg). No more than 20 pieces should be used in one day. Nicotine gum is usually recommended for 1 to 3 months, with the maximum being 6 months. Tapering the amount of gum chewed may help you stop using it.

If you have sensitive skin, you may prefer the gum to the patch. Another advantage of nicotine gum is that it allows you to control the nicotine doses. The gum can be chewed as needed or on a fixed schedule during the day. The most recent data have shown that scheduled dosing is more effective. A schedule of 1 to 2 pieces per hour is common. On the other hand, with an as-needed schedule, you can chew more gum during a craving.

Some possible side effects of the gum:

  • bad taste
  • throat irritation
  • mouth sores
  • hiccups
  • nausea
  • jaw discomfort
  • racing heartbeat

Symptoms related to the stomach and jaw are usually caused by improper use of the gum, such as swallowing nicotine or chewing too rapidly. The gum can also cause damage to dentures and dental prostheses.

Long-term dependence is one possible disadvantage of nicotine gum. In fact, research has shown that 15% to 20% of gum users who successfully quit smoking continue using the gum for a year or longer. Although the maximum recommended length of use is 6 months, continuing to use the gum is likely to be safer than going back to smoking. But since there is little research on the health effects of long-term nicotine gum use, most health care providers still recommend limiting its use to 6 months.

Nicotine nasal spray: The nasal spray delivers nicotine quickly to the bloodstream as it is absorbed through the nose. It is available only by prescription.

The nasal spray immediately relieves withdrawal symptoms and offers you a sense of control over nicotine cravings. Because it is easy to use, smokers report great satisfaction. However, the FDA cautions that since this product contains nicotine, it can be addictive. It recommends the spray be prescribed for 3-month periods and should not be used for longer than 6 months.

The most common side effects last about 1 to 2 weeks and can include the following:

  • nasal irritation
  • runny nose
  • watery eyes
  • sneezing
  • throat irritation
  • coughing

There is also the danger of using more than is needed. If you have asthma, allergies, nasal polyps, or sinus problems, your doctor may suggest another form of nicotine replacement.

Nicotine inhalers: Introduced in 1998, inhalers are available only by prescription. The nicotine inhaler is a plastic tube with a nicotine cartridge inside. When you puff on the inhaler, the cartridge provides a nicotine vapor. Unlike other inhalers, which deliver most of the medication to the lungs, the nicotine inhaler delivers most of the nicotine vapor to the mouth. In terms of similar behavior, nicotine inhalers are the closest thing to smoking a cigarette, which some smokers find helpful.

The recommended dose is between 6 and 16 cartridges a day, for up to 6 months.

The most common side effects, especially when first using the inhaler, include:

  • coughing
  • throat irritation
  • upset stomach

At this time, inhalers are the most expensive of the forms of NRT available.

Nicotine lozenges: These are the newest form of NRT on the market. The FDA recently approved the first nicotine-containing lozenge as an over-the-counter aid in smoking cessation. As with nicotine gum, the Commit lozenge is available in 2 strengths: 2 mg and 4 mg. Smokers determine which dose is appropriate based on how long after waking up they normally have their first cigarette.

The lozenge manufacturer recommends using it as part of a 12-week program. The recommended dose is one lozenge every 1-2 hours for 6 weeks, then one lozenge every 2-4 hours for weeks 7 to 9, and finally, one lozenge every 4-8 hours for weeks 10 to 12. In addition, the manufacturer recommends the following:

  • Stop all tobacco use when beginning therapy with the lozenge.

  • Do not eat or drink for 15 minutes before using the lozenge. (Some beverages can reduce the effectiveness of the lozenge).

  • Suck on the lozenge until it dissolves. Do not bite or chew it like a hard candy, and do not swallow it.

  • Do not use more than 5 lozenges in 6 hours, or more than 20 lozenges total per day.

  • Stop using the lozenge after 12 weeks. If you still feel you need to use the lozenge, talk to your doctor.

  • Do not use the lozenge if you continue to smoke, chew tobacco, use snuff or any other product containing nicotine (e.g., nicotine patch or gum).

Possible side effects of the nicotine lozenge include:

  • trouble sleeping
  • nausea
  • hiccups
  • coughing
  • heartburn
  • headache
  • flatulence (gas)

Which Type of Nicotine Replacement Is Right for You?

There’s no evidence that any type of nicotine replacement therapy is significantly better than any other. When choosing which type of nicotine replacement you will use, think about which method will best fit your lifestyle and pattern of smoking. Do you want/need something to chew or occupy your hands? Or are you looking for once-a-day convenience?

Some important points to consider:

  • Nicotine gums, lozenges, and inhalers are oral substitutes that allow you to control your dosage to help keep cravings under better control.

  • Nicotine nasal spray works very quickly when you need it.

  • Nicotine inhalers allow you to mimic the use of cigarettes by puffing and holding the inhaler.

  • Nicotine patches are convenient and only have to be applied once a day.

  • Both inhalers and nasal sprays require a doctor’s prescription.

  • Some people may not be able to use patches, inhalers, or nasal sprays due to allergies or other conditions.

Other Nicotine/Tobacco Products, Not Reviewed or Approved by the FDA

Combination of the patch and other nicotine replacement products: Using the nicotine patch along with shorter-acting products such as the gum, lozenge, nasal spray, or inhaler is another method of nicotine replacement therapy. The idea is to provide a steady dose of nicotine with the patch and to use one of the shorter-acting products when strong cravings arise.

The few studies that have been done on combination NRT have found that it may be slightly better than a single product, but more research is needed to prove this and to find safe and effective doses. The combined use of nicotine replacement products has not yet been approved by the FDA. If you are considering using more than one nicotine replacement product, be sure to discuss this with your doctor first.

Tobacco lozenges and pouches: Lozenges containing tobacco (Ariva, Interval) and small, tobacco-containing pouches (Revel, Exalt) are being marketed as alternative ways for smokers to get nicotine in places where smoking is not permitted, rather than as quit smoking aids. The FDA has ruled that these are a type of smokeless tobacco, not smoking cessation aids; therefore, the FDA does not have authority over them. There is no evidence that these products can help a person quit smoking.

Nicotine lollipops and lip balms: In the past, some pharmacies made a product called a "nicotine lollipop." These lollipops often contained a product called nicotine salicylate with a sugar sweetener. Nicotine salicylate is not approved for pharmacy use by the FDA. The FDA has warned several pharmacies to stop selling nicotine lollipops and lip balm on the Internet, and calling the products "illegal." The FDA also said "the candy-like products present a risk of accidental use by children."

Other similar tobacco cessation products may not use nicotine salicylate, and therefore may be legal. However, they still pose a risk for children if they are not sufficiently labeled and stored safely.

Nicotine water and nicotine wafers: These products have been sold in recent years as ways to get nicotine in places where smoking is not permitted. They are not marketed as aids to quitting smoking, but questions about their safety and legality have been raised.

Other Methods of Quitting

Other tools, used alone or in combination with nicotine replacement therapy, may improve your chances of quitting.

Zyban (bupropion) is a prescription antidepressant in an extended-release form that reduces symptoms of nicotine withdrawal. This drug affects chemicals in the brain that are related to nicotine craving. It can be used alone or together with nicotine replacement. The usual dosage is one or two 150 mg tablets per day.

In one study, Zyban helped 49% of smokers quit for at least a month. In the same study, 36% of nicotine patch users were able to quit for a month. When both methods were used, 58% of smokers were able to remain smoke free for over a month.

This medication should not be taken if you have a history of seizures, anorexia, heavy alcohol use, or head trauma.

Many experienced clinicians recommend combination drug therapy for heavily addicted smokers. One form of combination therapy is to combine the nicotine patch with a shorter acting nicotine replacement drug. Another is to combine bupropion with the patch as well as a short acting nicotine replacement.

Other Tools

Hypnosis might be useful for some people. Ask your doctor if he or she can recommend a good hypnotist if you are interested in this.

Acupuncture has been used for quitting tobacco, but as of yet there is no strong evidence to support its effectiveness. Acupuncture, when it is done, is typically done on the ears on particular ear sites. Although there is a very weak suggestion that acupuncture might lower the desire for smoking, there still is no solid evidence that it is truly effective as a smoking cessation tool. For a list of local physician acupuncturists, contact the American Academy of Medical Acupuncture at 1-800-521-2262. Low-level laser therapy is a related technique, which also has very little evidence to support its effectiveness.

Filters that reduce tar and nicotine in cigarettes are generally not effective since studies show that smokers who use filters actually tend to smoke more.

Smoking deterrents such as over-the-counter products that change the taste of tobacco, "stop smoking diets" that curb nicotine cravings, and combinations of vitamins have little scientific evidence to support their claims.

The same is true of “homeopathic” aids and herbal supplements. Because they are marketed as dietary supplements (as opposed to drugs), they don’t need FDA approval to be sold. The manufacturers don’t have to prove they’re effective, or even safe. Be sure to look closely at the product label of any product claiming it can help you stop smoking. No dietary supplement has been proven effective in helping people quit smoking.Some of these supplements have no nicotine in them, but have multiple combinations of herbal preparations. They too have no proven track record of helping people to stop smoking.

Atropine and scopolamine combination therapy: There is a program available to the public that administers an injection of atropine. Atropine produces many effects in the body, including relief from spasms of the gastrointestinal tract (stomach and intestines), the bladder, and the biliary tract. This is helpful in controlling conditions such as colitis, spastic bladder, diverticulitis, infant colic, renal and biliary colic, peptic ulcer, and irritable bowel syndrome. Atropine also has effects on the heart. It is used during surgery to maintain proper heart function, during emergencies involving the heart, and to treat certain heart disorders.

Scopolamine is used to relieve nausea, vomiting, and dizziness associated with motion sickness and recovery from anesthesia and surgery. It may also be used in the treatment of parkinsonism, spastic muscle states, irritable bowel syndrome, diverticulitis, and other conditions).

Scopolamine is an anticholinergic medicine, which has many effects in the body including decreasing the secretion of fluids, slowing the stomach and intestines, and dilation of the pupils.

The atropine and scopolamine combination therapy is given to a patient in an inpatient clinic on one day. Then the patient is discharged on medications of Donnatal or Phenobarbital, which is in a class of drugs called barbiturates. Phenobarbital depresses the activity of your brain and nervous system, causing relaxation. The patient takes the Donnatal for 14 days and the Scopolamine patches for 6 days, typically. The theory behind this program is that the medications used for smoking cessation take care of the physical withdrawal associated with quitting smoking. The psychological cravings continue.

The potential side effects of this treatment are: dizziness, constipation, dry mouth, an altered sense of taste and smell, problem urinating, blurry vision for 6-8 days. People who have a history of a recent heart attack, glaucoma, heart arrythmias or irregular rhythms, pregnant or have uncontrolled high blood pressure are not allowed to participate in these programs. The success rate claims to be high, but there is no published scientific research to back up that claim. Also, although the medications used in the program are FDA approved as claimed, they are not FDA approved for this specific use, which is misleading to the public.

A Word About Quitting Success Rates

Before you start using nicotine replacement or sign up for a stop smoking class or program, you may wonder what its success rate is. That's a hard question to answer for several reasons. First, not all programs define success in the same way. Does success mean that a person is not smoking at the end of the program? After 3 months, 6 months, or 1 year? If a program you're considering claims a certain success rate, ask for more details on how success is defined and what kind of follow-up is done to verify the rate.

The truth is, quit smoking programs, like other programs that treat addictions, often have a fairly low success rate. But that does not mean they are not worthwhile or that you should be discouraged. Your own success in quitting is what really counts, and that is under your control.

About 5% to 16% of people are able to quit smoking for at least 6 months without any medicine to help with withdrawal. Several articles in medical journals have reported that between about 25% and about 33% of smokers who use nicotine replacement or bupropion (Zyban) can remain smoke-free for over 6 months. There is early evidence that combining nicotine replacement therapy with bupropion may be more effective than either one alone.

Behavioral and supportive therapies increase success rates even further. Check the package insert of nicotine replacement products to see if the manufacturer provides free telephone-based counseling.

How to Quit

Smokers often say, "Don't tell me why to quit, tell me how." There is no one right way to quit, but there are some key elements in quitting smoking successfully. These 4 factors are crucial:

  • making the decision to quit
  • setting a quit date and choosing a quit plan
  • dealing with withdrawal
  • staying quit (maintenance)

Making the Decision to Quit

The decision to quit tobacco use is one that only you can make. Others may want you to quit, but the real commitment must come from you.

Researchers have looked into how and why people stop tobacco use. They have some ideas, or models, of how this happens.

The Health Belief Model says that you will be more likely to stop tobacco use if you:

  • believe that you could get a tobacco-related disease and this worries you
  • believe that you can make an honest attempt at quitting
  • believe that the benefits of quitting outweigh the benefits of continuing tobacco use
  • know of someone who has had health problems as a result of their tobacco use

Does any of these apply to you?

The Stages of Change Model identifies the stages that you go through when you make a change in behavior. Here are the stages as they apply to quitting tobacco use:

Pre-contemplation: At this stage, the tobacco user is not thinking seriously about quitting right now.

Contemplation: The tobacco user is actively thinking about quitting but is not quite ready to make a serious attempt yet. This person may say, "Yes, I'm ready to quit, but the stress at work is too much, or I don't want to gain weight, or I'm not sure if I can do it."

Preparation: Tobacco users in the preparation stage seriously intend to quit in the next month and often have tried to quit in the past 12 months. They usually have a plan.

Action: This is the first 6 months when the user is actively quitting.

Maintenance: This is the period of 6 months to 5 years after quitting when the ex-user is aware of the danger of relapse and take steps to avoid it.

Where do you fit in this model? If you are thinking about quitting, setting a date and deciding on a plan will move you into the preparation stage, the best place to start.

Setting a Quit Date and Deciding on a Plan

Once you've made a decision to quit, you're ready to pick a quit date. This is a very important step. Pick a specific day within the next month as your "Quit Day." Picking a date too far in the future allows you time to rationalize and change your mind. But do give yourself enough time to prepare and come up with a plan. You might choose a date that has a special meaning like a birthday or anniversary, or the date of the Great American Smokeout (third Thursday in November each year). Or you may want to simply pick a random date. Circle the date on your calendar. Make a strong, personal commitment to quit on that day.

There is no one right way to quit. Most tobacco users prefer to quit "cold turkey" – that is, abruptly and totally. They use tobacco until their Quit Day and then stop all at once, or they may cut down on tobacco for a week or 2 before their Quit Day. Another way involves cutting down on the number of times tobacco is used each day. With this method, you gradually reduce the amount of nicotine in your body. While it sounds logical to cut down in order to quit gradually, in practice this method is difficult.

Quitting tobacco is a lot like losing weight; it takes a strong commitment over a long period of time. Users may wish there was a magic bullet – a pill or method that would make quitting painless and easy. But that is not the case. Nicotine substitutes can help reduce withdrawal symptoms, but they are most effective when used as part of a stop tobacco use plan that addresses both the physical and psychological components of quitting.

Here are some steps to help you prepare for your Quit Day:

  • Pick the date and mark it on your calendar.
  • Tell friends and family about your Quit Day.
  • Stock up on oral substitutes – sugarless gum, carrot sticks, and/or hard candy.
  • Decide on a plan. Will you use nicotine replacement therapy? Will you attend a class? If so, sign up now.
  • Practice saying, "No thank you, I don't smoke."
  • Set up a support system. This could be a group class, Nicotine Anonymous, or a friend or family member who has successfully quit and is willing to help you.

Successful quitting is a matter of planning and commitment, not luck. Decide now on your own plan. Some possibilities include using the nicotine patch or gum, joining a tobacco cessation class, going to Nicotine Anonymous meetings, or using self-help materials such as books and pamphlets. For the best chance at success, your plan should include one or more of these options.

On your Quit Day, follow these suggestions:

  • Do not smoke.
  • Get rid of all cigarettes, lighters, ashtrays, and any other items related to smoking.
  • Keep active – try walking, exercising, or doing other activities or hobbies.
  • Drink lots of water and juices.
  • Begin using nicotine replacement if that is your choice.
  • Attend stop smoking class or start following a self-help plan.
  • Avoid situations where the urge to smoke is strong.
  • Reduce or avoid alcohol.

Dealing With Withdrawal

Withdrawal from nicotine has 2 parts – the physical and the psychological. The physical symptoms, while annoying, are not life threatening. Nicotine replacement can help reduce many of these physical symptoms. But most users find that the bigger challenge is the mental part of quitting.

If you have been smoking for any length of time, smoking has become linked with nearly everything you do – waking up in the morning, eating, reading, watching TV, drinking coffee, etc. It will take time to "un-link" smoking from these activities. That is why, even if you are using a nicotine replacement, you may still have strong urges to smoke.

One way to overcome these urges or cravings is to recognize rationalizations as they come up. A rationalization is a mistaken belief that seems to make sense at the time but is not based on facts. If you have tried to quit before, you will probably recognize many of these common rationalizations.

  • I’ll just use it to get through this rough spot.
  • Today is not a good day; I’ll quit tomorrow.
  • It's my only vice.
  • How bad is tobacco, really? Uncle Harry chewed all his life and he lived to be over 90.
  • You've got to die of something.
  • Life is no fun without smoking.

You probably can add more to the list. As you go through the first few days without tobacco, write down any rationalizations as they come up and recognize them for what they are: messages that can trap you into going back to using tobacco. Use the ideas below to help you keep your commitment to quitting.

Avoid people and places where you are tempted to smoke. Later on you will be able to handle these with more confidence.

Alter your habits. Switch to juices or water instead of alcohol or coffee. Take a different route to work. Take a brisk walk instead of a coffee break.

Alternatives. Use oral substitutes such as sugarless gum or hard candy, raw vegetables such as carrot sticks, or sunflower seeds.

Activities. Exercise or do hobbies that keep your hands busy, such as needlework or woodworking, that can help distract you from the urge to smoke.

Deep breathing. When you were smoking, you breathed deeply as you inhaled the smoke. When the urge strikes now, breathe deeply and picture your lungs filling with fresh, clean air. Remind yourself of your reasons for quitting and the benefits you'll gain as an ex-smoker.

Delay. If you feel that you are about to light up, delay. Tell yourself you must wait at least 10 minutes. Often this simple trick will allow you to move beyond the strong urge to smoke.

What you're doing is not easy, so you deserve a reward. Put the money you would have spent on tobacco in a jar every day and then buy yourself a weekly treat. Buy a magazine, go out to eat, call a friend long-distance. Or save the money for a major purchase. You can also reward yourself in ways that don't cost money: take time out to read, work on a hobby, or take a relaxing bath.

Staying Quit (Maintenance)

Remember the quotation by Mark Twain? Maybe you, too, have quit many times before. So you know that staying quit is the final, and most important, stage of the process. You can use the same methods to stay quit as you did to help you through withdrawal. Think ahead to those times when you may be tempted to smoke, and plan on how you will use alternatives and activities to cope with these situations.

More dangerous, perhaps, are the unexpected strong desires to smoke that occur sometimes months (or even years) after you've quit. To get through these without relapse, try the following:

  • Review your reasons for quitting and think of all the benefits to your health, your finances and your family.
  • Remind yourself that there is no such thing as just one cigarette – or even one puff.
  • Ride out the desire. It will go away, but do not fool yourself into thinking you can have just one.

What if you do smoke? The difference between a slip and a relapse is within your control. You can use the slip as an excuse to go back to smoking, or you can look at what went wrong and renew your commitment to staying off smoking for good.

Even if you do relapse, try not to get too discouraged. Very few people are able to quit for good on the first attempt. In fact, it takes most people several attempts before quitting for good. What’s important is figuring out what helped you in your attempt to quit and what worked against you. You can then use this information to make a stronger attempt at quitting the next time.

Special Concerns

Weight Gain

Many smokers do gain some weight when they quit. Even without special attempts at diet and exercise, however, the gain is usually less than 10 pounds. Women tend to gain slightly more weight than men. There is some evidence that smokers will gain weight after they quit even if they do not eat more.

For some, a concern about weight gain can lead to a decision not to quit. But the weight gain that follows quitting smoking is generally very small. It is much more dangerous to continue smoking than it is to gain a small amount of weight.

You are more likely to be successful with quitting smoking if you deal with the smoking first, and then later take steps to reduce your weight. While you are quitting, try to focus on ways to help you stay healthy, rather than on your weight. Stressing about your weight may make it harder to quit. Eat plenty of fruits and vegetables and limit the fat. Be sure to drink plenty of water, and get enough sleep and regular physical activity.

Walking is a great way to be physically active and increase your chances of staying quit. Walking can help you by:

  • reducing stress
  • burning calories and toning muscles
  • giving you something to do instead of thinking about smoking

No special equipment or clothing is needed for walking, other than a pair of comfortable shoes. And you can do it pretty much anytime or anywhere. Try the following:

  • walking around a shopping mall
  • getting off the bus one stop before you usually do
  • finding a buddy to walk with during lunch time at work
  • taking the stairs instead of the elevator
  • walking with a friend, family member, or neighbor after dinner
  • pushing your baby in a stroller

Set a goal of 30 minutes of physical activity 5 or more times a week. If you don’t already exercise regularly, please check with your doctor before starting an exercise program.

Stress

Smokers often mention stress as one of the reasons for going back to smoking. Stress is a part of all of our lives, smokers and nonsmokers alike. The difference is that smokers have come to use nicotine to help cope with stress. When quitting, you have to learn new ways of handling stress. Nicotine replacement can help to some extent, but for long-term success other strategies are needed.

As mentioned above, physical activity is a good stress-reducer. It can also help with the temporary sense of depression that some smokers experience when they quit. There are also stress-management classes and self-help books. Check your community newspaper, library, or bookstore.

Spiritual practices such as prayer and meditation have been used very successfully with other addictions and are an integral part of 12-step recovery programs. These same principles can be applied to quitting smoking and can help with stress reduction.

Where Can I Go for Help?

It is hard to stop smoking. But if you are a tobacco user you can quit! More than 46 million Americans have quit smoking for good. Many organizations offer information, counseling, and other services on how to quit as well as information on where to go for help. Other good resources where help can be found include your doctor, dentist, local hospital, or employer.

If you want to quit smoking and need help, contact one of the following organizations.

American Cancer Society
Telephone: 1-800-ACS-2345
Internet address: www.cancer.org

American Heart Association & American Stroke Association
Telephone: 1-800-AHA-USA-1 (1-800-242-8721)
Internet address: www.amhrt.org
Internet address: www.strokeassociation.org

American Lung Association
Telephone: 1-800-586-4872 (1-800-LUNG-USA)
Internet address: www.lungusa.org

Centers for Disease Control and Prevention
Office on Smoking & Health
Telephone: 1-800-CDC-1311 (1-800-232-1311)
Internet address: www.cdc.gov/tobacco

National Cancer Institute
Cancer Information Service
1-800-4-CANCER or 800-422-6237
Internet address: www.cancer.gov

Nicotine Anonymous
1-877-TRY-NICA (1-877-879-6422)
Internet Address: www.nicotine-anonymous.org

Smokefree.gov
(Online materials, including info on state Quitlines)
1-800-QUITNOW or 1-800-784-8669
Internet Address: www.smokefree.gov

Smoking Cessation Leadership Center
Internet Address: http://smokingcessationleadership.ucsf.edu/

References

American Cancer Society. Cancer Facts & Figures 2005. Atlanta, Ga. 2005.

American Cancer Society. Cancer Prevention & Early Detection Facts & Figures 2004. Atlanta, Ga. 2004.

Agency for Health Care Policy and Research, Clinical Practice Guideline on Smoking Cessation, No. 18, AHCPR, Rockville, MD, April 1997.

Centers for Disease Control and Prevention (CDC). Annual smoking-attributable mortality, years of potential life lost, and economic costs - United States, 1995-1999. MMWR Morb Mort Wkly Rep. 2002;51 300-303. Available at: www.cdc.gov/mmwr//preview/mmwrhtml/mm5114a2.htm. Accessed October 2004.

Centers for Disease Control. Best practices for comprehensive tobacco control programs – August 1999. Atlanta, GA: US Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1999.

Centers for Disease Control. Cigarette Smoking Adults – United States, 2003. Morbidity and Mortality Weekly Report. Atlanta, GA. Centers for Disease Control and Prevention. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/mm5420a3.htm. Accessed May 26, 2005.

Fiore MC, Smith SS, Jorenby DE, et al. The effectiveness of the nicotine patch for smoking cessation. A meta-analysis. JAMA. 1995; 273: 181.

Hurt RD, Sachs DPL, Glover ED, et al. A comparison of sustained-release bupropion and placebo for smoking cessation, New Engl J Med. 1997; 337:1195-1202.

Joad JP. Smoking and pediatric respiratory health. Clin Chest Med. 2000 Mar;21:37-46,vii-viii.

Peto R, Darby S, Deo H, et al. Smoking, smoking cessation, and lung cancer in the UK since 1950: combination of national statistics with two case-control studies. BMJ. 2000;321:323-329.

Schroeder SA. What to do with a patient who smokes. Grand Rounds at the University of California, San Francisco. JAMA. 2005; 294:482-487.

Stapleton JA, Russell MA, Feyerabend C, et al. Dose effects and predictors of outcome in a randomized trial of transdermal nicotine patches in general practice. Addiction. 1995; 90 :31-42.

Tonnesen P, Norregaard J, Simonsen K, et al. A double-blind trial of a 16-hour transdermal nicotine patch in smoking cessation. N Engl J Med. 1991;325::311-315.

Tonnesen P. Two and four mg nicotine chewing gum and group counseling in smoking cessation: an open, randomized, controlled trial with a 22 month follow-up. Addictive Behaviors. 1988;13:17-27.

Transdermal Nicotine Study Group. Transdermal nicotine for smoking cessation. Six-month results from two multicenter controlled clinical trials. JAMA. 1991;266:3133-3138.

US Department of Health & Human Services. The Health Benefits of Smoking Cessation: A Report of the Surgeon General. Centers for Disease Control and Prevention (CDC), Office on Smoking and Health. 1990. Available at: http://profiles.nlm.nih.gov/NN/B/B/C/T/. Accessed October 2004.

US Department of Health & Human Services. The Health Consequences of Smoking: A Report of the Surgeon General. Centers for Disease Control and Prevention (CDC), Office on Smoking and Health. 2004. Available at: www.cdc.gov/tobacco/sgr/sgr_2004/index.htm. Accessed October 2004

US Department of Health & Human Services. The Health Consequences of Smoking: Nicotine Addiction: A Report of the Surgeon General. Centers for Disease Control and Prevention (CDC), Office on Smoking and Health. 1988. Available at: www.cdc.gov/tobacco/sgr/sgr_1988/index.htm. Accessed October 2004.

US Department of Health & Human Services. Reducing the Health Consequences of Smoking: 25 years of Progress. A Report of the Surgeon General. Centers for Disease Control and Prevention (CDC), Office on Smoking and Health. 1989. Available at: http://profiles.nlm.nih.gov/NN/B/B/X/S/. Accessed November 2004.

US Department of Health and Human Services. Reducing Tobacco Use: A Report of the Surgeon General. Centers for Disease Control and Prevention (CDC), Office on Smoking and Health. 2000. Available at: www.cdc.gov/tobacco/sgr/sgr_2000/index.htm. Accessed November 2004.

Revised: 11/04/2005

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